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Dilation and Delivery: Management of Post-viable Parturients with Severe Subglottic Stenosis
Abstract Number: T-60
Abstract Type: Case Report/Case Series
We present the cases of two pregnant, post-viable patients (hereafter referred to as Patients A and B) presenting with severe symptomatic subglottic tracheal stenosis of 4mm with audible stridor. They both underwent microdirect subglottoscopy, CO2 laser incision, tracheal dilation and steroid injection at approximately 31 weeks and 26 weeks gestation, respectively. Anesthesia management involved use of manual intermittent jet ventilation, and total intravenous anesthesia (TIVA) with propofol and remifentanil. Obstetric management involved continuous fetal monitoring and readiness for immediate emergent cesarean section, if needed. Both patients tolerated the laryngoscopy, dilation, jet ventilation, and anesthesia without issue and continuous fetal monitoring was uneventful.
Patient A was discharged home on the day of tracheal dilation. She returned in spontaneous labor at 39 weeks, 5 days gestation. The patient remained without stridor or other airway symptoms throughout her labor and tolerated normal spontaneous vaginal delivery with one dose of intravenous fentanyl as her only labor analgesic.
Patient B remained inpatient for the duration of her antepartum course after her tracheal dilation for monitoring of her fetus’ concurrent intrauterine growth restriction. The obstetric operating rooms were equipped with multiple small size endotracheal tubes and airway exchange catheters with jet ventilation capabilities. The otolaryngology service was involved in her care over the subsequent 6 weeks and the patient had no recurrence of symptoms. At 31 weeks 3 days gestation a fetal ultrasound demonstrated reverse end-diastolic flow. At that time, initial plan was for induction of labor but the patient failed a contraction stress test and was subsequently taken to the operating room for primary cesarean section under single shot spinal anesthesia and her surgical delivery was without complication.
Reported cases of perioperative and peripartum management of parturients with tracheal stenosis, especially in those undergoing tracheal dilation using general TIVA and intermittent jet ventilation during viability, are extremely rare. Successful management of these complex patients requires timely intervention, excellent multidisciplinary care coordination, and regular assessment of airway status.
1. Carness, J.M. and J.L. Berman, Awake microlaryngoscopy and serial balloon dilation in a third trimester multigravida with subglottic tracheal stenosis: anesthetic implications. A A Case Rep, 2014. 3(12): p. 166-8.